1. Dealing with an Influenza Outbreak in the NW/UK Paul Baines MD MA MRCP FRCA Paul.Baines@alderhey.nhs.uk

3. How swine flu began...

4. Pandemic flu: managing demand and capacity in health care organisations (surge) http://www.dh.gov.uk/en/Publicationsandst atistics/Publications/PublicationsPolicyAnd Guidance/DH_098769

5. Pandemic flu: managing demand and capacity in health care organisations (surge) Over the entire period of a pandemic, up to 50% of the population may show clinical symptoms of influenza. This could result in the total healthcare contacts for influenza-like illness increasing from around 1 million during a ‘normal’ season up to 30 million; it will not be possible to refine estimates until a pandemic occurs and person- to-person transmission begins. Of those developing symptoms, up to 28.5% (including all affected children under one) will require assessment and treatment by a GP or other health professional, and up to 4% may require hospital admission if sufficient capacity is available. Average length of stay for those with complications may be six days (ten days if in intensive care). Of those who become symptomatic, up to 2.5% may die. At the peak of the pandemic, there could potentially be up to 440 new cases per 100,000 population requiring hospitalisation each week, 110 of whom could require access to critical care facilities.

6. Pandemic flu: managing demand and capacity in health care organisations (surge) General hospitals will be able to provide some high- dependency and intensive care services, particularly to older children, with paediatricians working closely with their general-trained anaesthetic colleagues. Local arrangements for providing this service to children should be explored before a pandemic occurs and should form part of local Demand and Capacity plans. In these circumstances, regional paediatric consultants and paediatric intensivists should provide clinical support and advice at a distance, as resources allow.

7. Pandemic flu: managing demand and capacity in health care organisations (surge) The decision to withdraw or limit interventions earlier in the course of a patient’s treatment than would be considered under normal circumstances is likely to cause distress to relatives and critical care staff, and the ability to continue functioning as a cohesive team will require careful attention to staff communication and morale. As there is likely to be extreme distress, anger and even a risk of aggressive behaviour from family and friends of those in whom withdrawal of treatment interventions must be considered, it may be advisable to rely on non-escalation (eg not commencing vasopressor support or renal replacement) in many situations. Lack of availability of drugs, equipment or expertise may independently restrict such interventions.

8. Inclusion and exclusion criteria from secondary care to intensive care Paediatric – inclusion criteria Paediatric – exclusion criteria Requirement for invasive ventilatory support Severe burns Hypotension with evidence of shock Head injury. Severe Burns Severe trauma Cardiac arrest – unwitnessed, witnessed but not responsive to electrical therapy, recurrent cardiac arrest Known, severe, progressive baseline cognitive impairment Known, advanced, untreatable neuromuscular disease Known, advanced, metastatic malignant disease Known, advanced and irreversible immunocompromise Severe and irreversible neurological event or condition End-stage heart, lung or liver failure.

9. Note the similarities!

10. Still children but definitely adult size

11. What age of child will your hospital be prepared to ventilate down to if ICU and ICU capacity becomes a problem? If aICUs ventilate 8-10 year olds it makes it more likely that 3 year olds will get into Alder Hey. If they don't then AHCH will ventilate 15 year olds but aICUs will ventilate more 3 year olds (or if they don't, what'll happen when there are no PICU beds?...see next question)

12. What are your trust's plans for children IF PICU capacity is overwhelmed (no PICU beds and no foreseeable PICU beds in Britain)?

13. Taken from "1918 Influenza: the Mother of All Pandemics" Jeffery K. Taubenberger and David M. Morens

14. Severe Respiratory Disease Concurrent with the Circulation of H1N1 Influenza Mexico 2009 http://content.nejm.org/cgi/content/full/NEJMoa0904023?query=TOC

16. 1918 Pandemic

17. 1918 flu epidemic: the Oakland Municipal Auditorium in use as a temporary hospital

18. How will we triage ICU patients? Entry and interval or progress triage Choose between patients or protect critical care beds

19. How will we triage ICU patients? Choose between an 8 and a 28 year old or a 48 year old all with flu. Or choose between a 5 year old with flu and a 25 year old RTA Or choose between a 5 year old RTA and a 25 year old Flu victim

20. Swine flu clinical package Paediatric Pathway http://www.dh.gov.uk/en/Publicationsandst atistics/Publications/PublicationsPolicyAnd Guidance/DH_100941